Category: Special Feature

:dropcap_open:R:dropcap_close:on walks through his department, musing at the firmly presented evidence of new plans and projects displayed on a large wall-mounted flat screen TV. At ChiroTouch, it’s all about transparency. Every employee must be able to quickly tour the office and gain a firm grasp of the latest projects.  In this way, they all stay connected. His team is responsible for helping him fortify yesterday’s foundation, and pioneer the next step in the never-ending quest for innovation. 

 

He unlocks his office door and casually flicks on the lights. The scene has changed over the years – from a small computer in his home, to a desk in a one-room office, to one in a large suite fit to support a full-fledged company, to this room; where a wraparound desk holds his various technologies, and plaques of accomplishment adorn the walls. Success is palpable in the halls around him as the buzz of activity continues to build. The rise of ChiroTouch has gained momentum, but for Ron the objective is the same: to make an outstanding piece of software.

 

One room to the right of Ron’s decorated office, his cohort Robert Moberg stands at the head of a large conference table behind a glass wall. He references a large monitor that displays one of his highly intricate spreadsheets (for which he is well-known throughout the company’s many diverse departments) and discusses the numbers as they relate to current happenings and far-reaching future plans. 

 

“And what do we do, in all that we do?” he asks his team, pausing with an encouraging smirk, “We consistently try to find ways to make it work, or make it better.”   He instills this value into every employee, helping them find their own strengths, harness their individual creativity, and apply themselves ceaselessly to  each and every new challenge. 

 

As Co-founder, Developer, and Chief Technology Officer of Integrated Practice Solutions, Ron McNeill established ChiroTouch through hard work, perseverance, and sometimes just plain stubbornness. The grassroots foundation was born in 1999 out of a single chiropractic provider’s request for an interface that would allow him to search through his patients by name. From this small application grew a full practice management solution unlike anything the chiropractic market had seen. Ron harnessed cutting-edge technology to build a solution that streamlined provider processes with touch screen interfaces, barcode and fingerprint scanner integration, and streamlined patient flow management. As a direct result of the heartfelt effort and continued innovations he’s instituted within the software, including industry-exclusive offerings of iPad integration and mobile phone patient communication portals, ChiroTouch has grown over time to become the industry standard for the chiropractic market.

 

But not all of this success came without its hard times, which are evidenced in the stories he is prodded to recant at every yearly meeting to help new employees understand the heart of the company. It’s an important initiation for newcomers, and a reminder for others that they must understand, at a very personal level, the special endeavor in which they’ve been invited to participate.

 

Success also did not come overnight, and for the first 5 years, providers were hesitant to adopt a new system within their practice which meant ChiroTouch users were few and far in between. But even throughout a barely-climbing client count, Ron forged ahead. He queried his users for input, provided them with tireless support, and diligently stationed himself at every trade show. Now one of the largest booths in attendance, ChiroTouch was once nothing more than a small table, one chair, and one man with a lot of drive and perseverance. And from those experiences, he now reminds his staff that it’s important to respect every player within the industry.

 

“When you go to a tradeshow, watch for the little guy in the corner and realize that he may not look like much. But I was once that little guy in the corner, and now look around you at what we’ve built.”

 

In 2004, Ron partnered with his then-client, a well-respected Seattle chiropractor, Dr. Michael Failla. Under Dr. Failla’s charismatic and enthusiastic watch, ChiroTouch began to find its way into chiropractic offices across the country. Dr. Failla’s own testimony and particular empathy with the challenges of running a high-volume practice helped him encourage his fellow peers to decrease their practice expenses, increase their efficiency, and get back to the most important part of running their practice—treating their patients. 

 

By 2008, ChiroTouch was ready to start breaking ground at a faster pace. Recruited for his strong business acumen and prowess, Robert Moberg took the helm of company operations in June of 2008, and steered the ship towards a goal that would make ChiroTouch more than just a provider solution. It would become a comprehensive chiropractic resource. 

 

“With the amount of heart and care for chiropractic that I saw in this company, its owners, and its employees,” said Robert, reflecting on his first days on board, “I knew we had to do more than provide for our community. We had to truly participate.” 

 

Robert believes that integrity and clarity of purpose and culture must be ingrained in everything a company does, and is a critical part of making an impact.  Known for his ‘question the questioner’ tactics to encourage his staff to dig deeper and really challenge themselves, Robert has brought together a team of individuals who do more than row the oars; they are tasked to bring their best ideas to the table and help him navigate and build upon the ship. He brings encouragement during struggles and invites team members to find and introduce new tools to the ChiroTouch workshop. In this way he has built a company of leaders and thought innovators who believe passionately in their work and share their individual successes with the whole.

 

Over his first few years, the economic downturn became an important concern for Robert, as more and more providers were losing the capability to find lenders, and requirements tightened up as times grew tough. As providers knocked and were turned away by other banks and software companies, Robert decided to open the door. From this decision spawned IPS Financial and ChiroTouch began to finance providers who would have otherwise been left behind. 

 

“We had to find ways to allow them to experience the financial benefits that came with EHR adoption,” Robert said. “After all, if you are struggling in tough financial times, what better lifesaver is there to throw than an application that helps you save money?”

 

On the heels of the economic downturn also came the American Recovery and Reinvestment Act and the HITECH Act, prompting EHR vendors to make comprehensive adjustments to their software and offer their providers the ability to receive sizable incentives based on Medicare reimbursements. Wanting to ensure that every chiropractor had the opportunity to collect on this incentive, ChiroTouch worked tirelessly to adapt the software to meet these requirements, and built a department specifically to meet the needs of clients looking to navigate their way through the process. These efforts proved worthwhile in early 2013 when the number of ChiroTouch clients who had received reimbursements surpassed those of any other competing software system in chiropractic. 

 

But IPS Financial and the EHR Incentive Program weren’t the only things that had Robert’s attention. He spoke passionately about his commitment to the chiropractic industry, and his vision of sharing research and knowledge with others by creating a platform for chiropractic. It was time to start participating more fully in a community that gives so much to improve the health and wellness of their clients. He began to envision a platform where industry leaders could share their knowledge for the betterment of chiropractic. 

 

By partnering with many of the industry leaders and binding with the foundation of the chiropractic community, ChiroTouch created a stage for which to showcase these community leaders and provide a library of information that could help both ChiroTouch clients and their peers alike. For Robert this endeavor wasn’t about selling, it was all about giving back to the community.  So ChiroTouch began offering free webinars by industry leaders such as Drs. Patrick Gentempo, Bob Hoffman, Brad Glowaki, and Ron Oberstein, among many others. After receiving a great deal of positive feedback, the webinar program grew, and became a parallel purpose for the company that was very central to its core beliefs. When asked to reflect on the endeavor, Robert has nothing but good news to share. 

 

“ChiroTouch has offered hundreds of free webinars over the course of the last few years. The response has been thrilling and humbling. We really feel like we’re helping create a supportive and educational platform from which to spread information among chiropractic providers and their peers.”

 

ChiroTouch stepped out further to invest in the community by donating to the Foundation for Chiropractic Progress, supporting their mission of generating positive press for the chiropractic profession. Life Chiropractic College West was also on the list of support, to help aid those dedicated to chiropractic from day one. 

 

While Robert continued to build a network throughout the nation by supporting State Association events, partnering with industry leaders, and donating to key foundations, Ron had his eye on another way to help chiropractors get a leg up. He was ready to introduce the idea of true mobility. 

 

Ron’s keen sense for leveraging the latest technology has been pivotal in defining new technology platforms that can be applied to the industry, and in creating additional tools to assist chiropractic providers. Ron’s approach included maintaining a sounding board for clients, and consistently reaching out to providers to help him anticipate the active needs of the industry. By understanding how to direct the efforts of ChiroTouch, Ron has worked tirelessly to revolutionize patient care through never-before-seen innovations built on a platform of automation, mobility, and efficiency.

:quoteright_open:As the years have gone by, the immediate goals of the company have often changed to meet the fluctuations of our team, our clients, and our community.:quoteright_close: 

Ron recruited his team to begin working on a new idea: building native iPad apps. With the mobility of an iPad, doctors would no longer be chained to their computer. They could engage their patients more fully, and move about the office in freedom. In turn, patients could sit comfortably and fill out their information on an iPad while they waited. And best of all, providers could connect to their patient database and practice information from anywhere they had mobile Internet or Wi-Fi access. 

 

Along with the mobility provided with the All-in-One Provider, Outcomes Assessments, and Self Check-In iPad apps; online scheduling also hit the streets, allowing chiropractic providers to schedule patients while they were out and about in the world. This new flexibility brought providers the ability to schedule patients on the fly, resulting in increased appointments and fewer scheduling mistakes. Chiropractors could now use online scheduling to review their schedule at any time, and therefore more easily maintain a healthy work-life balance. 

 

The feedback from doctors on this breakthrough mobility and the continued innovations in the application was outstanding, as was the reception of the community to the efforts put forth by ChiroTouch to support the chiropractic industry. With such a remarkable history, there was left nothing to do but look to the future. 

 

Those first mobile apps were just the tip of the iceberg. And with positive feedback under his belt and a sense that chiropractors were ready to embrace any new technology he could get their hands on, Ron put his idea-making machine into overdrive. What was next? Where else could he go? 

 

He’d built software that could automate the daily tasks of the provider, increase efficiencies, and streamline practice processes; but what about the patients? Ron began brainstorming ways to not just connect a chiropractor’s activities within the office, but to connect their practice to their patients even while those patients were outside of office doors. With smartphone in hand, Ron began building MyChiroTown: a phone application that gives patients access to educational information, products and services, coupons, appointment scheduling, self check-in, directions, and more, all through an interface that could be customized for each specific practice and its patients. 

 

With the availability to access practice information at their leisure, MyChiroTown offers patients the ability to connect with their chiropractors and receive information while they’re on the go.  With this novel phone app, the connection and communication between patients and providers can begin to become much, much closer. 

 

The bustle starts to slow, and the halls begin to clear. Although some faces still peer studiously at their computer screens and a few client calls are being diligently tended to; the company wheel has set up camp for the night.

 

Ron flicks off his light, closes his door, and walks back through his department. The plans and projects still display brightly on the monitor, but progress has ticked another day forward. Old items are off the list, and new ones full of the promise of tomorrow have taken their place.  

 

“Many of the projects I ask them to tackle are challenging,” Ron says in reference to his team, “But I don’t hire people who don’t like to be challenged. There is a number one requirement for those who work for our company. You have to care about the work you do here. If you don’t care, you don’t belong here. “

 

Dr. Michael Failla seconds that notion, saying, “I’m so proud of what we’ve accomplished. The positivity that this company has continued to put forth into every fabric of its being, and the sense of purpose that every single one of us shares is not built or destroyed overnight. We’ve established roots in the chiropractic community, and we mean to tend to our garden for a good, long time to come.”

 

Robert clears his desk of clutter, making sure everything goes back in its place. He shoots off a few last e-mails and wraps up for the day. As he pauses outside his door, those in the cubicles to his left nod goodnight. They are the remaining support, sales, operation, and IT staff who are finishing up client calls and following up on requests. Robert doesn’t have to wonder why any of them are still here. He knows as well as anyone who works at ChiroTouch. And when asked, he does not have to mull over his response. 

 

“As the years have gone by, the immediate goals of the company have often changed to meet the fluctuations of our team, our clients, and our community. But our purpose has never changed. We exist to enrich the lives of the chiropractors that we serve so that they may enrich the lives of the patients they serve. It’s as simple and straightforward as that.”

 

:dropcap_open:W:dropcap_close:hen it comes to marketing your practice, it may feel overwhelming when you try to plan where to start or how to change your office’s current strategy because there are so many options to choose from in the practice management arena. There are many marketing “experts” in our profession with the goal of helping you make your practice successful. They range from classic practice management companies that delve into the details of your practice to companies that cold-call our offices and want to charge us per patient once they call. We still have print media and, of course, the Internet offers instant access to many options to boost your practice.

 

Even though many marketing techniques can work for chiropractors, often they depend on your personality, the type of practice you want to have, and how much money you want to spend. Now, I know you wisely have money allocated to market your practice, and that amount is up to you. So let’s talk about some low-cost and no-cost marketing tools we can use to get the word out in the community about what we do. 

 

I have always opted for looking at my patient population and educating them before, during, and after they are patients in my office. As chiropractors, we typically are pigeonholed as back and neck doctors. Many of our patients are unaware that we treat much more. Since I’ve built my practice on extremity work, I make sure my patients and the general public understand that. 

 

I love trying to see how much free advertising I can milk from the mediums available to us. Let me give you a few ideas and see what you think about using them for your practice.

 

People assume that every business has a website these days, but just having a website is not good enough. You need to make sure you take time to write some of the content yourself. People are looking at your website, making judgments, and getting first impressions of you. If you are a sports practitioner, do you use ART or have a laser? If a potential patient can’t easily learn this from your website, make it more visible. My practice is rooted in the feet and extremities, so that information is all over my website. 

 

Take the time to make sure your website exudes quality and professionalism, and understand that cheaper is not always better. Ask five of your friends to critique your website. Better yet, ask your next five new patients if they bothered to look up your website and ask for their opinions. This is the only real area where I invest money because it keeps me “out there” for patients to learn about my practice and has helped me grow my business tremendously.

 

The general public often uses social media sites such as Facebook, Twitter, LinkedIn, Google+, Google Places, and Yelp. People are now more tech savvy these days about the Internet. Although some sources like to say that Facebook’s popularity has declined, over half of its users check in every day, and some still look at it first thing in the morning and the last thing before bed. 

 

Establish a Facebook professional page that is separate from your personal page. It’s generally not a good idea to “friend” patients on your personal page. Often, you can post short little tidbits about office hours, specials, and events on Facebook, LinkedIn, and Google+, as well as tweet about them on Twitter. Unless you choose to pay specifically for advertising, these social media outlets are free to use. 

 

Do you have something to share? Did you have an interesting case that you want all of your patients to know you treated well? Then write about it. Don’t groan about this because the key is making it short and sweet by writing only a few paragraphs. You can post links to your articles, blogs, and newsletters on your social media pages. Also, when you write new content for your website, you site is well indexed—search engines such as Google love fresh content.

 

Be careful about blogging and writing pieces that are too long. Write short pieces unless you are so passionate about your topic that you just can’t hold back. People do not have the time or the inclination to read articles or posts if they are too long or too frequent. If you love blogging and writing newsletters, make sure you put them out only once or twice a month. If you publish much more than that, patients may start deleting or unsubscribing. Patients will react the same way you would if someone was e-mailing you too often.

4. Use silent marketing in your practice.
I hate being a salesman, but I am very good at it. Like you, I do not appreciate people being in my face about things they think I need. I focus much of my practice on evaluating and adjusting the feet. Few patients have been exposed to any of this and many of them have no clue as to why this could be important.

So I use displays, brochures, posters, product samples, and my office staff’s knowledge to give subliminal cues to prompt people to ask questions. Often, patients play with my shoe and orthotic displays while they wait for me to take them back to the treatment room.

This will work well for those of you who work with a lot of nutritional supplements, exercise and rehabilitation, and other things. Let silent marketing sell for you. Education usually equals acceptance.

5. Stay up to date on technology and tell everyone about it.
Patients notice if you keep current with the times. When you look at new technology, don’t just dismiss it without thinking it through using your heart and your business sense. Many available technologies can do amazing things for our patients. If you can help your patients, stay current with new technology, and have it be financially advantageous for your chiropractic business, then why not? “Oh, I just don’t want to spend the money.” I get it because I’ve been there.

However, when you look at technologies like the 3-D foot scanners, lasers, vibration plate therapy, fancy chiropractic tables, or whatever item you are thinking about bringing into your practice, use your head and don’t let fear be the reason you decline. Talk to your CPA or financial adviser for guidance. If you can get a write-off or depreciate the equipment while you offer a new service to your patients, then everyone wins.

If your patients do not know all the conditions or problems you can help people with in your office, it’s not their fault—it’s yours! Patient education happens gradually, but hopefully it advances each time you encounter your patients. I know you probably have read these types of articles already, but I hope you gleaned something new from my five tips. You’ll know that you are doing a good job with patient education when referrals start to flow into the practice. It’s especially nice to receive referrals for cases not typically considered classic chiropractic.

Dr. Kevin Wong is an expert on foot analysis, walking and standing postures and orthotics. Teaching patients and chiropractors is a passion for him, and he travels the country speaking about spinal and extremity adjusting. Dr. Wong practices full-time in Orinda, California. Contact Dr. Wong at 925-254-4040 or [email protected].

:dropcap_open:J:dropcap_close:anuary 1, 2014 is the official date that the Healthcare Portability Act (Obamacare) goes into effect. How you start to position your practice today literally can make or break your practice going forward. While nobody knows with 100% certainty whether the new law will help or hurt the healthcare industry, in the following article I will do my best to tell you what my crystal ball says. The nice thing about my crystal ball is that, whether it is right or wrong, by heeding the suggestions in this article, you will be protected and well on your way to insuring that your practice thrives. Change is always scary, but change can be good if you are prepared for it.

 

The Patient Protection and Affordable Care Act, also known as the ACA, healthcare reform, or Obamacare is the law passed in March 2010 to help Americans buy, afford, and maintain health insurance or other payer coverage for their health and medical needs. In June 2012, the Supreme Court ruled that almost all aspects of the law were, in fact, constitutional. While the ruling didn’t serve to calm the dissent, the law continues to be implemented according to a specific timetable which will culminate in 2014 with total implementation of the law.

 

According to James Lehman, DC, in his article published in Dynamic Chiropractic Practice Insights, February, 2011: “As of the current state of the law, the Affordable Care Act permits chiropractors to function as members of the primary care team. The language in the bill ensures that doctors of chiropractic can be included on these patient-centered and holistic teams. The non-discrimination provision lifts some of the burden imposed by unfair limitations of certain insurance companies.

 

The article continues to report:

 

Now that the explanation of the new law is clear as mud, let’s take a look at a couple of scenarios that can play out.

 

Scenario #1: In 2014, a flood of new patients come into the office now that they have health insurance. Remember, the probability is that these new patients will be allowed a minimum number of visits at a nominal reimbursement rate.

What to do now:

1. Learn how to perform a proper consultation that creates value for your patient.
2. Learn how to communicate the value of what the patient will receive under care.
3. Learn how to convert the patient to a cash-paying patient once the minimal insurance runs out.
4. Make sure that your procedures will be able to handle an influx of new patients.
5. Make sure that your staff is amply trained to handle the extra flow.
6. Make sure your organizational skills will afford you the ability to manage more patients.
7. Create meaningful follow-up campaigns for those patients that choose to leave care after their insurance runs out.

Scenario #2: Everything that occurs in the first scenario, but in 2015, insurance companies wake up and realize that all of their newly insured clients have “flooded” the system. Insurance companies are forced to raise premiums 300% (yes, 300%). Co-pays rise to a normal rate of $85 per visit (they are close to that now in the Carolinas) and normal deductibles rise to $1,500 (many plans are $1,000 now). When patients are forced to pay $85 per visit and have a $1,000–$1,500 deductible, essentially a cash practice is created.

What to do now:

1. Build up cash reserves that equal one year of business and personal expenses. Do this by starting small. Just put away $2 per day every day.
2. Learn all of the communication skills listed in scenario #1. The only way to thrive is to be able to create tremendous value for your patient in the consultation and every visit there-after.
3. You must learn to market strategically, not tactically.
4. You must be well organized so you will have time to market, train, and work on your practice.
5. You must become business-savvy.
6. You will want to develop cash-based services in addition to your insurance-based services.

:dropcap_open:Being prepared is the key to achieving success during any transition.:quoteleft_close:

Analysis: No matter what happens, you will be well positioned to run a successful practice and business in any environment. If Obamacare causes a flood of a continuation of new patients, your organization, proper staff training, ability to perform a value consultation, and your communication skills will allow that patient to continue with you for the long haul. If the world implodes and insurance co-pays and deductibles act as deterrents to patients obtaining care, you will be well positioned to run a cash practice. In addition, you will have taken defensive measures to ensure that your cash reserves will be able to carry you through any downward transition.

Being prepared is the key to achieving success during any transition. Since nobody has any certainty about what will happen with the new law, it is incumbent upon practitioners to position themselves in a way that their practices will continue to survive and thrive no matter what happens. Remember, you can do anything that you put your mind to. If you are unable or unsure about what to do, ask a friend, colleague, or hire a professional to help you. Please do not bury your head in the sand by taking no action at all. That is a surefire recipe for disaster.

Dr. Paul S. Inselman, President of Inselmancoaching, is an expert at teaching chiropractors how to build honest, ethical, integrity-based practices based on sound business principles. From 2008-2012 his clients practices grew an average rate of 145% while the general profession was down 28%. His 26 years of clinical experience coupled with 10 years of professional coaching has allowed him to help hundreds of chiropractors throughout the nation. He can be reached at 1-888-201-0567 or to schedule a free no obligation consultation go to https://www.timetrade.com/book/JNW2J . His e-mail is [email protected] .
 

:dropcap_open:I:dropcap_close: recently had an opportunity to visit the Chiropractic Department at Walter Reed National Military Medical Center (WRNMMC). As a component of the Physical Medicine and Rehabilitation Department, it was inspiring to see chiropractic integrated with multiple specialties. I was fascinated as I observed the dedication of a variety of professions applied to the revitalization of wounded warriors through sophisticated treatment protocols, technology, and the rebuilding of self-esteem. The miracles I witnessed there were important and moving, both personally and professionally. It was a thrill to see chiropractic and the tools of our trade used to improve the lives of so many wounded warriors.

 

This is an interesting time. It seems as if we are constantly urged by our national associations, the ACA and ICA, to contact our congressional representatives and senators to encourage them to cosponsor chiropractic legislation. The hot button right now is S. 422, or the Chiropractic Care Available to All Veterans Act. Personally, I have been a little confused by this for years. After all, didn’t Congress pass a bill more than ten years ago that put DCs in VA hospitals and on military bases? Sure they did, and it was H.R. 3447 (107th Congress): Department of Veterans Affairs Health Care Programs Enhancement Act of 2001. However, if it seems that the implementation has not been comprehensive, then here’s the bill’s requirement: “The Secretary shall designate at least one site for such program in each geographic service area of the Veterans Health Administration.”1  So, if you have thought that coverage is not thorough, now you know why. However, the new bill is a great enhancement to this, stating: “Chiropractic Care Available to All Veterans Act of 2013—Amends the Department of Veterans Affairs Health Care Programs Enhancement Act of 2001 to require a program under which the Secretary of Veterans Affairs provides chiropractic care and services to veterans through Department of Veterans Affairs (VA) medical centers and clinics to be carried out at: (1) no fewer than 75 medical centers by December 31, 2014, and (2) all medical centers by December 31, 2016.” 2

 

I  have enjoyed a full-time private chiropractic practice in northern Virginia since 1982. My office is only about 15 miles from the Pentagon, and is close to many other military and federal installations. I feel honored to have assisted the health of thousands of active and retired military and their dependents. One of my earliest practice memories was working with a colonel named Neil who had been a Vietnam prisoner of war for more than seven years. I will always treasure that learning experience. In chiropractic school, we are told that our patients will refer others like themselves, and from the beginning, I have always had military patients. However, even with their great sacrifices, they have not had chiropractic treatment as one of their well-earned benefits. Even with a few DCs on nearby bases, there simply is not enough coverage for all those in need. Passage of bills like S. 422 and others would enhance military access to our services. According to Harold Kudler, MD, of the VA, the most commonly reported health issue of returning soldiers is musculoskeletal.3 

 

With all of this in mind, I have developed a curiosity of what it might be like to visit an operating chiropractic department at a military facility. In March, at the National Chiropractic Legislative Conference in Washington, DC, I was fortunate enough to meet William Morgan, DC, chief of chiropractic services at Walter Reed National Military Medical Center. 

The unassuming Dr. Morgan, who prefers to be known as just Bill, was gracious enough to accept my request to visit him at the hospital. Keep in mind, I was expecting to see straightforward chiropractic, but what I saw far exceeded my expectations.

The purpose of my story is not to list Dr. Morgan’s (Bill’s) lengthy accolades. His CV is book length and his numerous awards are, if you ask me, “too many to count.” (If interested, visit: http://drmorgan.info/home.) What I want to convey, though, is that I experienced a very friendly, caring, energetic guy who is excited about his work, has an unselfish desire to share, and possesses a terrific command of the subject. Bill told me he is just an average chiropractor, but I beg to differ.

I drove to Walter Reed on a sunny Thursday afternoon and the capital-area traffic had not yet ramped up. Getting past security at the north gate was a little tricky, even though Bill had me put on the access list. They don’t let just anyone in to Walter Reed, but after explaining the purpose of my visit, I was allowed to enter. With parking my next challenge, I found a space high up in the garage next to the new hospital building, the America Building. Bill called me just as I parked and guided me to the clinic. Then he said, “Meet me at the piano.” Piano? I found that interesting, but I’ll get back to that later.

We were in Bill’s office for only a couple of minutes. It was a fairly typical chiropractic treatment room: diagnostic equipment, elevating Leander table with auto flexion, hydrocolator tank, ultrasound unit, cold laser, etc., all strategically placed around the room. Bill also explained that this room was also his office; there was a desk, a computer for documentation and research, and an extra monitor to view imaging. Given space limitations, Bill chose to have an additional treatment room over a private office. Before I knew it, we were out of the office and starting the tour.

The Chiropractic Department shares a front desk with three other clinics: Occupational Therapy, Orthotics/Prosthetics, and Physical Medicine and Rehabilitation. It was the beginning of a discovery of integration as it should be.

:dropcap_open:Ross is a firearms instructor who trains recovering soldiers to fire weapons using their newly fitted prostheses.:quoteleft_close:

Our first stop was the Department of Occupational Therapy in Rehabilitative Services, where I met salty retired Navy SEAL, Recreational Therapist Ross Colquhoun. Ross is a firearms instructor who trains recovering soldiers to fire weapons using their newly fitted prostheses. It is a “can-do” atmosphere that I perceived to be far more about the reestablishment of self-esteem and confidence than the newly developed dexterity required to regain proficiency with firearms. After working with a large variety of soldiers’ injuries over the years, Ross has become tremendously creative toward finding ways to teach positional adaptation to fitted prostheses. More importantly, though, Ross establishes the concept that a soldier will regain his belief that he is capable to return to his previous level of ability.

Additionally, Ross is the outdoor “field and stream” manager. It is one thing to be cooped up in a state of the art rehabilitation center, but he also manages to get many guys out into the great outdoors and do something fun and physical. Hunting and fishing is very popular, including an annual event on the Eastern Shore during “Waterfowl Weekend.” Those interested get to enjoy four days of “hunting, freedom, and honor” hosted by American Legion Post 18. It is not only for experienced hunters, but also for others who discover they really can be capable once again. Here they have an opportunity to enjoy their newly developed arms proficiency without being in combat. Soldiers who had seen their young lives flash before them are reinvigorated by success found through fishing, hunting, crossbow, or biking. The newfound confidence in their physical capability is just as important as rehabilitating wounded soldiers’ mangled limbs. Inside or out, Ross Colquhoun’s contributions are great!

Next stop was the CAREN-Lab, which stands for Computer Assisted Rehabilitation Environment. This is a 9’ x 9’ high-tech motion platform with an embedded treadmill with force plates. The platform can move in every direction as well as rotate. It is suspended in front of a large curved screen on which virtual application scenes are projected along with surround sound, making it all seem very real. Nine motion capture cameras record the movements of the subject on the platform. Patients are harnessed on the platform and learn to improve and rehab gait and balance by following the path of the projected scene. Everything is recorded by the cameras and the force plates. Data is collected, computer analyzed, and progress is regularly evaluated.

The CAREN-Lab is used for amputees and those with traumatic brain injuries, vision impairment, and neurological diseases that cause ambulatory deficits. The soldiers referred by their physicians to the lab are highly motivated to be as they were prior to injury, or better. This safe, controlled place challenges the physicality of rehabilitation while expediting and improving the rehab process. In my discussions with both Bill and the lab techs, I heard a consistent theme: “It’s all about the best possible care for our wounded warriors.”

It is becoming evident that Bill is intrigued by the use of high technology to aid in advancing the quality of care. I think his favorite stop was at the GAIT lab. This large interesting room is actually the Biomechanics Laboratory and it has 23 motion-capture cameras strategically positioned to record the complex coordinated interactions between the lower limbs and the body during walking and running. Through computerized analysis, objective details of joint movement and associated forces help aid and develop clinical decision making to optimize treatment plans and correct prosthetic alignment.

The technology of the GAIT Lab largely contributed to Bill’s development of a trial study for the Fifth Joint National Capital Region Research Competition Symposium at Walter Reed. It was called “Reduction of Elective Amputations: Restoration of Function through Manual Extremity Manipulation.” At the time of my visit, 70 “case report posters” had been submitted and Bill’s Chiropractic Department’s entry was one of six finalists in the “staff and fellow” category. Stephanie Johnson, DC, now in practice in Alexandria, Virginia and a recent program intern who worked with Bill on the study, let me know that they placed second in the competition.

Bill explained that there are cases where injured patients with salvaged limbs ultimately opt for elective amputation if they don’t reach their level of functional expectations. He has found that failure can be related to limited range of motion caused by scar tissue adhesions, though. These are circumstances where chiropractic extremity procedures have been found to reach an effective level of increased function, thereby eliminating the contemplation of ultimate elective amputation. The GAIT Lab was a great place to objectively measure and record before and after progress made via chiropractic procedures.

Major Tammy Phipps is the lead driving instructor at Walter Reed. Her main objective is helping multiple amputees drive again. What is prioritized, though, is not so much about driver training or simulators; it is more about giving these wounded warriors, who have sacrificed and lost so much, the opportunity to regain personal dignity. There is a clear philosophy in this department: “Driving revives self-esteem and speeds recovery.”

Major Phipps explained to me that all effort is made on an individual, case-by-case basis to develop a vehicle adaptable to their prostheses and limitations. If a wounded warrior wants to drive, they will find a way to fit a vehicle to his needs. The gains in confidence and mental health are worth the time and cost. Additionally, there is supplemental funding available to amputees to assist in the modification of a vehicle for use in civilian life.

Back at the Chiropractic Department, Bill introduced me to another staff DC, Dr. Terence Kearney, along with longtime chiropractic assistants Rosie and Sharlene. Each treatment room is well equipped. Along with terrific integration with the other physical medicine departments, they do what we love to do: chiropractic. They treat a variety of patients, with the most challenging being, of course, the seriously “wounded warriors.” But like you and me, they also see the whole gamut of spine-related things we see every day as they treat active military, including high-ranking officers and VIPs. Just before we headed out, a young intern dropped by, Jeff Smee from NYCC. Another great thing about this operation is the opportunity some students get to work with Bill as an intern. I have met a few, including Jeff and Stephanie Johnson, who worked on the Gait Lab trial. Bill attracts highly qualified students who leave the intern program benefiting from a terrific learning experience, which is great for our profession.

Bill helped me find my way back to the parking garage. As we approached the large main entrance again, a young soldier beautifully playing the piano mesmerized me. Everyone present stopped what they were doing and just listened. Bill explained that this was not unusual. The arts remain extremely important here and it is just another way to feel normal through recovery. On top of that, well-known performers might just stop by and play a few tunes. I couldn’t help but imagine Billy Joel or Elton John rocking out at Walter Reed.

As I thanked Bill for a fun tour and interesting day, I commented that I was quite taken by all the great people I had met, the camaraderie, and the cooperative attitude of all the departments. I was also impressed especially by the overriding concept of what this hospital is willing to do to revive our wounded warriors, not only physically and functionally, but also mentally. Everywhere I went the theme seemed to be: rebuild the confidence, the self-esteem, the self-worth. To this, Bill responded, “Our nation is indebted to those who have placed themselves in harm’s way on our behalf. We strive to show every wounded hero the depths of our nation’s gratitude.”

He went on to explain that arrival at Walter Reed from combat operations is a very emotional scene. Typically, they are greeted by the admiral in charge of the hospital and an ICU contingent. Frequently, family members are present, and even more importantly, other wounded warriors. They drive home the point that not long ago, they too were mangled. With hard work ahead, though, new patients can count on healing, pulling their lives back together, and once again feeling functional and vital. The mentor side of it is just as important as the treatment. Most importantly, Bill said, they are received with a hero’s welcome.

Reference:

1. 107th Congress, 2001–2002. Text as of Jan 04, 2002 (Passed Congress/Enrolled Bill)
2. The Library of Congress, Thomas, Bill Summary & Status 113th Congress (2013 – 2014) S.422.
3. Source “Painting a Moving Train” ,Harold Kudler, M.D., Department of Veterans Affairs, and LCDR Erin Simmons, United States Navy, February, 2010.

David B. Dolberg, DC is a 1981 graduate of NYCC and has been in private practice in Springfield, Virginia since 1982. He is the 2012 Unified Virginia Chiropractic Association Chiropractor of the Year and has served as its Treasurer since 2008. He also recently became the ACA State Delegate for Virginia.

:dropcap_open:I:dropcap_close:’ve warned people about the dangers of soda for more than 16 years, and the list of reasons to avoid the beverage just keeps getting longer. Americans in particular get most of their daily calories from sugar, primarily in the form of high fructose corn syrup (HFCS) in soda and other sweetened beverages.

 

Half of the US population over the age of two consumes sugary drinks on a daily basis,1 and this figure does not even include 100% fruit juices, flavored milk, or sweetened teas, all of which are sugary too, so the figure is actually even higher.

 

Many people mistakenly believe that as long as you drink fruit juice, then it’s healthy even though it’s sweet. This is a dangerous misconception, though, and it fuels the rising rates of weight gain, obesity, fatty liver disease, high blood pressure, and type 2 diabetes in the United States and other developed nations.

 

It’s important to realize that sugary drinks, such as soda and even fresh-squeezed fruit juice, contain fructose, which has been identified as one of the primary culprits in the meteoric rise of obesity and related health problems—in large part due to its ability to turn on your “fat switch.” 

 

So-called “enhanced” water products are another source of hidden fructose and/or artificial sweeteners, which can be even worse for your health than sugar. I recommend drinking plenty of pure water as your primary beverage of choice instead. 

 

Preliminary research presented at the American Heart Association’s Epidemiology and Prevention/Nutrition, Physical Activity, and Metabolism 2013 Scientific Sessions (EPI/NPAM) suggests sugary beverages are to blame for about 183,000 deaths worldwide each year, including 133,000 diabetes deaths, 44,000 heart disease deaths, and 6,000 cancer deaths. 

 

Among the 35 largest countries in the world, Mexico had the highest death rates associated with sugary beverage consumption. In Mexico, the average consumption of sugary beverages was 24 ounces per day. 

 

Bangladesh had the lowest death rates. The US ranked third with an estimated 25,000 annual deaths2 from sweetened drinks.3 (Many might have expected the US to come in first place, but remember that American processed foods contain far more sugars than other nations, so Americans also consume a lot of “hidden” sugar in products other than beverages.)

 

Interestingly, and quite disturbingly, the death rates associated with sweetened beverages were highest in those under the age of 45. According to the featured article:4

 

“[W]hile the connection between excess sugar and chronic disease is well-known, the latest research is the first to quantify deaths correlated with sugared drinks worldwide…

 

To reach their conclusion, the scientists analyzed data from the 2010 Global Burden of Diseases Study and recorded how much sugar-sweetened beverages people drank, dividing up the data by age and sex. Then, they figured out how the various amount corresponded to obesity rates. 

 

Lastly, they calculated how much obesity affected diabetes, heart disease and certain cancers and determined the mortality rates from these diseases, ending up with the number of deaths that could be attributed to consuming sugary beverages by age and sex.”

 

Coauthor Dr. Gitanjali Singh told Time magazine:

 

 

As you may recall, New York City Mayor Michael Bloomberg recently tried to ban the sale of sugary beverages over 16 ounces in restaurants, food carts, and theaters, but the day before the ban was scheduled to go into effect, a New York State Supreme Court justice overturned it.5 Bloomberg has stated he intends to appeal the decision.

Personally, I believe the most appropriate strategy is to educate people on the facts about sugar consumption and encourage personal responsibility. Taxation and eliminating sweet drinks from schools and other venues may have a beneficial effect, but to really put a dent in the problem, you need to be properly informed about the consequences of your choices. Voting with your pocketbook and avoiding purchasing these products will cause them to disappear from the marketplace as companies will not produce items that don’t sell.

Scientific Statement from American Heart Association about Sugar Consumption and Heart Disease Risk
In 2009, the American Heart Association (AHA) issued a scientific statement6 about sugar intake and heart health, pointing out that there is evidence for a relationship between the two. According to the abstract:

“High intakes of dietary sugars in the setting of a worldwide pandemic of obesity and cardiovascular disease have heightened concerns about the adverse effects of excessive consumption of sugars.

In 2001 to 2004, the usual intake of added sugars for Americans was 22.2 teaspoons per day (355 calories per day). Between 1970 and 2005, average annual availability of sugars/added sugars increased by 19%, which added 76 calories to Americans’ average daily energy intake. Soft drinks and other sugar-sweetened beverages are the primary source of added sugars in Americans’ diets. Excessive consumption of sugars has been linked with several metabolic abnormalities and adverse health conditions, as well as shortfalls of essential nutrients…

[T]he American Heart Association recommends reductions in the intake of added sugars. A prudent upper limit of intake is half of the discretionary calorie allowance, which for most American women is no more than 100 calories per day and for most American men is no more than 150 calories per day from added sugars.”

How Much Sugar Do You Eat or Drink Each Day?
Let’s start with soda. One hundred calories isn’t much. Just one 12-ounce regular soda contains about 140 calories, which is the equivalent of 10 teaspoons of sugar. Similarly, one 8-ounce glass of orange juice has about eight full teaspoons of sugar, and at least 50 percent of that sugar is fructose. Drinking just one 8-ounce glass of orange juice will wallop your system with about 25 grams of fructose, which is more than you should have the entire day.

:dropcap_open:Around 100 years ago, the average American consumed a mere 15 grams of fructose a day, primarily in the form of whole fruit.:quoteleft_close:
Fructose has been identified as one of the primary culprits in the meteoric rise of obesity and related health problems, and while the majority of the problem is caused by the large quantities of high fructose corn syrup added to so many processed foods and sweetened beverages, naturally occurring fructose in large amounts of fruit juice is also a problem. Fructose is also a likely culprit behind the millions of US children struggling with non-alcoholic liver disease, which is caused by a build-up of fat within liver cells. Fructose is very hard on your liver, in much the same way as drinking alcohol.

Around 100 years ago, the average American consumed a mere 15 grams of fructose a day, primarily in the form of whole fruit. One hundred years later, one-fourth of Americans are consuming more than 135 grams per day (that’s over a quarter of a pound!), largely in the form of soda and other sweetened beverages.

Fructose at 15 grams a day is unlikely to do much harm (unless you suffer from high uric acid levels). However, at nearly 10 times that amount it becomes a MAJOR cause of obesity and nearly all chronic degenerative diseases. As a standard recommendation, I strongly advise keeping your total fructose consumption below 25 grams per day. However, for most people it would actually be wise to limit your fruit fructose to 15 grams or less, as it is virtually guaranteed that you will consume “hidden” sources of fructose from most beverages and just about any processed food you might eat.

Don’t Fall for the Latest “Designer Water” Fad
As a general rule, I advise drinking water as your primary form of beverage. Many simply do not drink enough water these days. But don’t be fooled by slick marketing. There are a number of “designer water” products available, and none of them can really beat plain, pure water. For example, on April 1, Coca-Cola released its latest enhanced water product called “Fruitwater,” which is described as “a great tasting, naturally flavored zero calorie sparking water beverage.”7 Despite its name, the product does not contain any juice. Rather it’s sweetened with sucralose and “natural fruit flavors.” Sucralose (Splenda) is an artificial sweetener that, like aspartame, is associated with a host of side effects, including:

• Gastrointestinal problems
• Seizures, dizziness, and migraines
• Blurred vision
• Allergic reactions
• Blood sugar increases and weight gain

Artificially Sweetened Water Is a Recipe for Poor Health
Different artificial sweeteners have been found to wreak havoc in a number of different ways. Aspartame, for example, has a long list of studies indicating its harmful effects, ranging from brain damage to pre-term delivery. Sucralose has been found to be particularly damaging to your intestines. A study8 published in 2008 found that sucralose: 

• Reduces the amount of good bacteria in your intestines by 50 percent
• Increases the pH level in your intestines
• Affects a glycoprotein in your body that can have crucial health effects, particularly if you’re on certain medications like chemotherapy, or treatments for AIDS and certain heart conditions

In response to this study, James Turner, chairman of the national consumer education group Citizens for Health, issued the following statement:9

“The report makes it clear that the artificial sweetener Splenda and its key component sucralose pose a threat to the people who consume the product. Hundreds of consumers have complained to us about side effects from using Splenda and this study…confirms that the chemicals in the little yellow package should carry a big red warning label.”

That was nearly five years ago, yet many are still in the dark about these health risks. Having healthy gut flora is absolutely vital for your optimal health, so, clearly, any product that can destroy up to half of your healthy intestinal bacteria can pose a critical risk to your health! Many are already deficient in healthy bacteria due to consuming too many highly processed foods. This is why I recommend eating fermented vegetables every day, or at the very least taking a high quality probiotic.

Believe me, if you continuously destroy up to 50 percent of your gut flora by regularly consuming sucralose, then poor health is virtually guaranteed. So please, do not make “Fruitwater” a staple drink thinking you’re doing something beneficial for your health…Remember, pure water is a zero calorie drink. You cannot find a beverage that contains fewer calories. If you think about it, why on earth would you choose artificially sweetened water over regular mineral water? If you want some flavor, just squeeze a little bit of fresh lemon or lime into mineral water as they have virtually no fructose.

Unfortunately, most public health agencies and nutritionists in the United States still recommend these toxic artificial sweeteners as acceptable and even preferred alternatives to sugar, which is at best confusing and at worst seriously damaging the health of those who listen to this well-intentioned but foolish advice. Contrary to popular belief, research has shown that artificial sweeteners can stimulate your appetite, increase carbohydrate cravings, and stimulate fat storage and weight gain. In fact, diet sodas may actually double your risk of obesity—so much for being an ally in the battle against the bulge.

The Case Against Bottled Waters
While we’re on the subject of commercially available water products, let me remind you that bottled water in general is a bad idea. Not only are you paying about 1,900 percent more for the same or similar water you get straight from your tap, water stored in plastic bottles has other health risks as well. The plastic often used to make water bottles contains a variety of health-harming chemicals that can easily leach out and contaminate the water, such as:

• Cancer-causing PFOAs
• PBDEs (flame retardant chemicals), which have been linked to reproductive problems and altered thyroid levels
• The reproductive toxins, phthalates
• BPA, which disrupts the endocrine system by mimicking the female hormone estrogen

If you leave your water bottle in a hot car, or reuse it, your exposure is magnified because heat and stress increase the amount of chemicals that leach out of the plastic. So the container your water comes in needs to receive just as much attention as the water itself, and plastic is simply not a wise choice from a health perspective, not to mention the extreme amounts of toxic waste produced!

What’s the Healthiest Beverage You Can Drink?
Sweetened beverages sweetened with sugar, HFCS, naturally occurring fructose, or artificial sweeteners are among the worst culprits in the fight against obesity and related health problems, including diabetes, heart disease, and liver disease, just to name a few. Remember that sweetened beverages also include flavored milk products, bottled teas, and “enhanced” water products. Ditching all of these types of beverages can go a long way toward reducing your risk for chronic health problems and weight gain. So what should you drink?

Your best, most cost effective choice is to drink filtered tap water. The caveat though is to make sure you filter your tap water. I’ve written a large number of articles on the hazards of tap water, from fluoride to dangerous chemicals and drugs, as well as toxic disinfection byproducts and heavy metals, so having a good filtration system in place is more of a necessity than a luxury in most areas. Remember, nothing beats pure water when it comes to serving your body’s needs. If you really feel the urge for a carbonated beverage, try sparkling mineral water with a squirt of lime or lemon juice.

Another option to consider is to bottle your own water from a gravity-fed spring. There’s a great website called FindaSpring.com where you can find natural springs in your area. This is a great way to get back to nature and teach your children about health and the sources of clean water. The best part is that most of these spring water sources are free! Just remember to take either clear polyethylene or glass containers to collect the water so no unsafe chemicals can contaminate your water on the way home. If you choose to use glass bottles, be sure to wrap them in towels to keep them from breaking in the car.

References:

1. CNN August 31, 2011
2. WebMD.com March 19, 2013
3. CNN March 19, 2013
4. Time magazine March 20, 2013
5. New York Daily News March 11, 2013
6. Circulation August 24, 2009 [Epub ahead of print]
7. FoodNavigator-USA.com March 19, 2013
8. Journal of Toxicology and Environmental Health 2008;71(21):1415-29
9. GlobeNewsWire.com September 22, 2008

Dr. Joseph Mercola is a Chicago-based osteopathic physician armed with more than 20 years of clinical experience. In 1997, he founded Mercola.com, which is now one of the leading natural health websites in the world.  Please visit Mercola.com for more information on Dr. Mercola.

:dropcap_open:I:dropcap_close:n February of 2011, I wrote in The American Chiropractor magazine, “Why is a life in Tennessee, South Dakota, and Texas worth more than a life in Hawaii and New York?” There is really no reason other than insurance companies and state politicians allow it to be. We are a country of laws and regulations, and these laws dictate the marketplace and reimbursements for doctors’ services. In most states, it is based upon the usual and customary fees of the doctors and the carriers paying a percentage of those fees. However, in states like New York, the state sets the doctor’s fees and they are driven by politics at their ugliest.

 

The collections listed in the following table depict what fees chiropractors collected as of May 2013 on a per-visit basis for a typical treatment versus fees collected in February 2011. They are rated against the cost of living for each state in comparison to other states. The dollar amounts exclude examinations, x-rays, supports, and any other ancillary services or testing.  

 

These numbers of reporting doctors do not reflect a large enough sample size to reflect the average. However, the numbers do reflect accurate amounts that can be collected. I choose to publish the highest amount reported by doctors per state. If a carrier will pay a doctor for one visit using the parameters above, then that is the potential for collections in that state. In some states, the highest number was not available, so the amount cannot be lower than reported.

 

As I established in my article in 2011, cost of living is not an indicator for reimbursement in personal injury as one would logically conclude. In a reasonable system, the more it costs to rent an office and run a business, the more doctors should be entitled to charge and collect. Unfortunately, politics determine your fees on a state-by-state basis and the stronger the insurance lobby, the lower the reimbursable fees. 

 

As it was reported in 2011, and as it is still consistent today, two of the most expensive states to live in are New York and Hawaii, yet they have the lowest levels of reimbursement nationally. New York, which in spite of its ranking as 47th for cost of living, undoubtedly a result of its vast rural areas, pushes it out of the highest ranking. However, a 500-square-foot office in downtown New York City can cost $7,000 per month to rent, yet the maximum reimbursement a chiropractor can receive is $43 per visit, no matter what services the doctor provides. In addition, if the carrier sends for an IME after a few visits in order to limit the amount of care, a further reduction in the doctor’s ability to receive fair and equitable reimbursement may occur. 

 

The reimbursement comparison between 2011 and 2013 revealed a potential 9% increase in collections for a personal injury visit on average when you combine all of the states. This statistic revealed a trend in the chiropractic profession that the personal injury population of patients is a financially stable sect within the industry. (Please note that this author is not suggesting that a doctor maximize his or her charges inappropriately and that only clinically indicated services should be performed based upon clinical necessity.)

 
:dropcap_open:The solutions are a strong political lobby with a unified chiropractic voice both nationally and statewide.:quoteleft_close:

Many doctors who read this report will feel that they must increase those portions of their practices with personal injury patients. From a reimbursement perspective and business plan, that would appear to make sense. However, is that doctor qualified? Treating trauma cases requires a very specific skill set and training no different than any specialist in any health care field. You wouldn’t want a psychiatrist performing open-heart surgery without the requisite training. At the very least, a doctor of chiropractic should have basic training in MRI interpretation and triaging the injured. Understanding the difference between a herniated, bulged, extruded, or migrating disk is critical in creating an accurate diagnosis, prognosis, and treatment plan in triaging and guiding the patient through care. Although the delivery of chiropractic may not change, when you can and cannot treat your patient might change because collaborative care with a medical specialist and or surgeon might be indicated. The etiology of pain in the trauma case is often dramatically different from in a chronic pain geriatric or pediatric patient.

 

The only way to spiral upward in success is through clinical excellence and the acquisition of knowledge and skill sets. Based upon past and currently published research, chiropractic outcomes have outpaced most other forms of treatment for conditions within our scope to treat. As a profession, the most direct avenue for these published studies to help increase utilization is for each doctor to be expert and credentialed in the area of desired practice. Treating personal injury patients is included in this formula.

 

In personal injury or any financial category, fair and equitable reimbursements will determine if a doctor can afford to live in any community nationally, and wise legislators will take into account the reimbursement statistics so as not to be “penny wise and dollar foolish,” unlike those elected officials in New York and to a lesser extent in Hawaii. The solutions are a strong political lobby with a unified chiropractic voice both nationally and statewide. 

 

References:

 

:dropcap_open:T:dropcap_close:rending: this word is what should be the guiding force behind the future of every practice and business worldwide. Why is it that some offices seem to thrive in any economy, yet others are always struggling to pay the rent, the staff, the bills and often oneself? How many weeks a year do you NOT take a paycheck? In 1982, John Naisbitt wrote the New York Times bestseller Megatrends, which accurately prognosticated shifts in the world economy and changed the relationship of people to economics. The principles of success in foretelling the future that held true in 1982 still hold true today. If you know where to look and how to interpret the economic or practice indicators, you will ensure your success for years to come IF you are willing to adapt based on the trends and indicators and IF you are willing to take the action steps required.

 

These changes have nothing to do with how you practice. You can be a “far-right conservatist” practicing in a pure “Tic” environment or a “far-left liberal” using every modality, treating extremities, using nutrition and every other avenue your scope allows, or somewhere in the middle like the majority of us. The rules are the same for all. Trends dictate how we triage, document, bill and collect our fees, not how we deliver chiropractic care to our patients.

 

When looking for trends in a professional setting, we must examine what the carriers, chiropractic boards, courts and legislators are dictating through rulings and legislation. First, we cannot be Pollyannaish and think that the carriers are outside influencing any of the above entities, as their profit base is purely derived from rules, regulations and laws. When looking at trends, we look for bellwethers nationally, and currently there are 2 states that are leading the pack, New York and, to a greater degree, New Jersey. 

 

The First Trend Is Evidence-Based:

In December, 2010 New York revamped its workers’ compensation guidelines, mandating evidence in the form of peer-reviewed literature to expand the amount of reimbursable care. New York also forbade treating workers’ compensation patients in a fee-for-service scenario outside of the workers’ compensation system. This changed the historical usual and customary amount of care based upon a doctor’s findings to that centered on the literature. Although this was limited to workers’ compensation, it laid the foundation for future legislation.

 

On January 4, 2013 New Jersey enacted regulation that says:

 

 

Evidence-based practice is NOT the trend. A perversion of what evidence-based practice was intended to be has become the trend and is here for the foreseeable future. In order to understand the trend, we must understand evidenced-based practice as it was intended. “The most common definition of evidence-based practice (EBP) is taken from Dr. David Sackett, a pioneer in evidence-based practice. EBP is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research'”

(Schardt & Mayer, 2010, http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm).

 

EBP is the integration of:

“The evidence, by itself, does not make a decision for you, but it can help support the patient care process. The full integration of these three components into clinical decisions enhances the opportunity for optimal clinical outcomes and quality of life. The practice of EBP is usually triggered by patient encounters which generate questions about the effects of therapy, the utility of diagnostic tests, the prognosis of diseases, or the etiology of disorders. Evidence-based practice requires new skills of the clinician, including efficient literature searching, and the application of formal rules of evidence in evaluating the clinical literature”

(Schardt & Mayer, 2010, http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm).

 

There are a myriad of articles published on the cons related to a purely evidence-based “published only” approach and its potential to be used to deny care. In a recent article by Carr (2008), published in the Journal of Regional Anesthesia and Pain Medicine, he writes, “Yet even as I was preparing that talk, the climate of pain medicine was changing. It was already clear that powerful stakeholders in the healthcare enterprise were looking to evidence-based medicine (EBM) for answers about effectiveness, cost effectiveness, appropriateness, and even efficacy beyond what EBM could reasonably provide. Since then, over- and mis-application of EBM to support health policies such as ‘pay for performance’ and to restrict payment has created a crisis. This ongoing crisis threatens the survival of important forms of pain therapy, restricting health care offered…” (Carr, 2008, p. 229). The biggest concern in his article and among healthcare providers is clarified when he states, “…I realized that the practice of EBM dates to antiquity, but what is new today is that EBM is being used as a rationale to restrict physician payment and/or autonomy” (Carr, 2008, p. 229).

 

Proponents of evidence-based, clinical guidelines published in peer-reviewed journals argue that it would eliminate waste and reduce costs while providing patients with the most up-to-date care available. That is a dangerous partial truth. Those currently practicing don’t argue, but understand, through daily patient care, that this is too limiting and would eliminate many procedures that fall under this narrow definition and remove clinical decision making and professional experience from the equation. What would be left is denial of valid and often critical therapies with the concurrent stifling of innovation, since the process of establishing a research study, following its participants and publishing those findings can take many years. This delay could eventually cost lives and/or severely diminish the quality of life for those who could have been helped during the research and publication processes.

 

With the understanding of EBP, the legislation in New Jersey has set forth a path that ONLY therapies and diagnostic testing that have been published are reimbursable with far-reaching effects. The trial lawyers’ concerns are that non-published tests or treatments will be barred as evidence in the courts with further implications not yet illuminated, as future court rulings will further define this regulation.

 

Although managed care companies and workers’ compensation carriers are not regulated, within weeks of the regulation becoming effective, denials were being rendered quoting these standards. The carriers took it to the next step and cited “standard of care” as a result. These same types of denials are being reported in multiple other states because the carriers realize that the rationale has been clearly defined and, in the end, many courts will uphold their reasoning, again citing “standard of care”. Therefore, the first significant megatrend in chiropractic is to utilize peer-reviewed evidence.

 

The second trend is credentials and certifications:

In the Fall of 2012, a trial court in New Jersey ruled that the chiropractor for the plaintiff was not allowed to testify on MRIs for his patient because of his insufficient certification (and credentials) in the “eyes of the court” on MRI interpretation. During direct and cross-examination, the specifics of this doctor’s MRI education were clearly detailed and the judge went further and ruled that ALL chiropractors in New Jersey couldn’t testify on MRIs based upon this one doctor’s account of his training.

:dropcap_open:Therefore, the second significant megatrend in chiropractic is to be prepared with the appropriate credentials and certifications. MRI spine interpretation is only one example. :quoteleft_close:

This ruling, which is being challenged in the appellate division and has amicus briefs by both the Association of New Jersey Chiropractors and the New Jersey Association for Justice (Trial Lawyers Association in New Jersey), has far-reaching negative implications for our profession, both locally and nationally, should it be both upheld and followed blindly by other judges. This judge cited how this one doctor’s MRI course was structured and monitored along with the content and institutions accrediting the certification in his ruling. Understanding the needs of the courts and the power of credentials, 3 different doctors during the week of February 17, 2013 testified in 3 different courts, and in each instance the same qualifying questions were asked as in the case where the one doctor was ruled against. In all 3 recent cases, the DCs were qualified as experts and allowed to testify on MRI. These 3 doctors understood that it is no longer “business as usual” and although their treatment protocols haven’t changed, they have chosen to ensure that they are qualified as expert. These doctors were certified by the Federation of Chiropractic Licensing Boards, the University of Bridgeport College for Chiropractic and the State University of New York at Buffalo School of Medicine and Biomedical Sciences for CE and AMA Category 1 PRA credits in MRI spine interpretation. These credentials were ruled by the courts as acceptable for DCs to be expert in interpreting MRI.  These credentials, unlike those obtained by the other doctor, have met not only New Jersey court standards, but those of every other state where they have been challenged in court.

 

This, too, has far-reaching implications for the chiropractic profession. The limited reach is being able to treat personal injury patients, with both lawyers and patients not fearing the loss of cases as a result of involvement by a chiropractor because the doctor of chiropractic will not be able to represent them in court. The long-term implication is the courts will now view chiropractors as well-credentialed experts on par with all other specialists, and when future utilization issues are considered, we will not be considered subservient. Therefore, the second significant megatrend in chiropractic is to be prepared with the appropriate credentials and certifications. MRI spine interpretation is only one example.

 

Solution:

In order to meet the trends for today and the future, we all must meet the “highest standard” in the nation regardless of our individual state’s requirements. Do the New York or New Jersey laws affect you in your state? Maybe or maybe not, but, given time, some form of these standards WILL affect you and your practice, whether it be today, tomorrow, next week, next month or next year. These are the indicators of today and demonstrate that you must be prepared.

:quoteright_open:To accomplish this, your choices are either to go to Google Scholar, Pubmed or Ovid and hunt for each citation or use a service that provides you with those citations.:quoteright_close: 

When documenting care in your records, you should strongly consider adding peer-reviewed evidence in your reports to support your recommendations. To automate the process, your EMR (electronic medical records) program should have macros to add those citations. To accomplish this, your choices are either to go to Google Scholar, Pubmed or Ovid and hunt for each citation or use a service that provides you with those citations (Historically, the latter has not been an expensive option.). Either way, this is a trend that cannot be overlooked and gives you a much deeper appreciation for the research community and what it provides to the chiropractic profession. 

 

Credentials are important, but the right credentials are critical, and whether you get cross-credentialed with another profession or a diplomate within chiropractic shouldn’t matter. The only criteria should be learning the material and having credentials that are legally defensible.  Learning how to perform an EMG, interpret an MRI or rehabilitate the paraspinal musculature, although integral to the practice of chiropractic, is not knowledge exclusive to chiropractic. However, the credentials and subsequent certifications are crucial for the DC to be able to function in today’s economy and the trends of the courts that we currently see in most states dictate that a continuing education course lasting a few hours, given by your state organization in a hotel, is often nothing but a great start.

 

New Jersey is a prime example and, thankfully, those 3 doctors (with many more to come) who were in court last week chose to go beyond the few hours in a hotel room and instead got certified.  Over time, more and more New Jersey (and other states’) courts will recognize that chiropractors are qualified to render expert opinion on MRI and overcome the negative opinion of this one judge, protecting chiropractic and your right to represent your patients and your profession. As a result of this case being an Allstate case, it is one that is significant, as this is one of the wealthiest carriers in the world, literally, who has the ability to leverage this lower court ruling nationally. Having DCs in other courts in New Jersey recognized as experts after the fact of this ruling minimizes the impact of this one judge’s ruling and essentially limits the negative influence of that case only to its specific facts and circumstances, and not to the entire profession as viewed by that one New Jersey court.

 

With these 3 doctors, was it necessary to get credentialed through a chiropractic university and earn category 1 AMA PRA credits through a medical school in addition to the chiropractic state board for the doctor’s chiropractic license? No. However, the judge saw these credentials and the work that was required for the certification as meeting much more stringent standards and qualified the doctor of chiropractic as expert. That is meeting the standard at the highest level and winning as a profession through clinical excellence.

 

No matter your philosophy, politics or manner of practice, this is where the profession is trending today and the near future. You need to meet the highest standard in the nation and let everyone else wonder why you are always doing well while THEY continue to struggle. 

 

References:

 

:dropcap_open:T:dropcap_close:he concept of evidence-based practice (EBP) is a recent innovation in health care that strives to combine the best available scientific evidence with the doctor’s clinical expertise, in line with the preferences of the patient, to improve treatment outcomes.1 Those who find EBP unpalatable are often the victims of its improper application by third-party payers or other independent auditors of clinical care, who may find it convenient to rely too heavily upon the research leg as they neglect the clinical expertise of the doctor or, worse, the preferences of the patient. As an example, if a patient is against surgical intervention and in favor of pursuing a chiropractic approach to resolving a condition, all of the research in the world in favor of surgery is irrelevant, and only the chiropractic data need be considered. If no such data exists, EBP standards then suggest the doctor’s clinical expertise is sufficient to justify the chosen approach. Since nearly half of all medical procedures currently in use appear to lack sufficient evidence to justify their use,2 quite often the clinical expertise of the doctor is the primary deciding factor in the judicious application of care. When used properly, EBP “facilitates the process of practitioners finding solutions to their patients’ individual clinical problems.”3 For those who may have been unjustly injured by an improper application of EBP, I offer one ironic statistic in hopes of alleviating the bitterness. According to a study published by Straus et al. in the Canadian Medical Association Journal in 2000,4 the process of evidence-based practice itself has not been evaluated according to its own standards. So, although suggestive evidence exists in favor of this,5 we cannot claim with certainty that following these standards truly results in improved patient outcomes. Regardless of this fact, understanding the principles of EBP is fast becoming a necessity in the 21st century healthcare arena. Considering that most chiropractors do not possess an understanding of basic research principles,6 this should be a matter of serious concern for our profession. In this article, I aim to educate the clinical chiropractor about some of the basics of research methods and the proper application of EBP as it pertains to whole-body vibration (WBV) therapy, and to aid them in making the correct statements regarding the safety and effectiveness of this increasingly popular therapy.

:quoteleft_open:First, it is important to understand that research terminology is often confusing in its exactitude:quoteleft_close: 

First, it is important to understand that research terminology is often confusing in its exactitude. The apparently contradictory nature of this statement can be resolved by considering two studies. The first is by Clinton Rubin,7 lead researcher whose department received funding from NASA to study the potential of WBV therapy to prevent bone and muscle loss in astronauts. This study showed that WBV therapy successfully prevented bone loss in postmenopausal women. Compare this to a randomized trial, which found no effect of WBV therapy in postmenopausal women.8 These two studies say the exact same thing — essentially, there was no change in bone mineral density (BMD) after WBV treatment — but one frames it as a success and the other as a failure. One key point to remember when evaluating research articles is this: No evidence of effect is not the same as evidence of no effect.9 To misquote F. Scott Fitzgerald, “The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.”

 

So, while we must recognize that the appropriate standards for the use of WBV therapy as a potential treatment for any condition have not yet been established or verified for any segment of the population,10 we should also realize that EBP is in favor of efforts to advance our understanding of WBV therapy and continues to justify its use under carefully controlled circumstances. However, this confusion is often exploited by marketers, so the responsible researcher is right to encourage caution and a “buyer beware” type mentality. Claims made by advertisers must be evaluated with great care, as the evidence is contradictory, even in the area where the greatest research on WBV therapy has been performed, namely osteoporosis. In regards to WBV therapy and osteoporosis, the honest man will tell you that some studies show good results, while others report no results, and hopefully opine that further research is needed to understand this apparent contradiction (in research circles, the technical term for this is “job security”). One of the reasons for the conflicting research has to do with the high number of variables involved with WBV therapy. Totosy de Zepetnek et al. quoted five factors that influence the response of the human skeletal system to WBV therapy (vibration direction, frequency, magnitude, duration, and body position),11 but this still leaves out the variables that occur within the population being studied. Prescription drug use,12 nutritional and hormonal status,8 gender, and age13 are just a few of these variables that could influence the results, and provide false information to the busy clinician who is ultimately seeking specific benefits for specific patients in the office. If all of the various types of WBV are placed together into one category without understanding how the involved variables can alter the critical effects experienced by the patient, this will confound the data and render it invalid. 

 

The Bone and Joint Decade calculated that the financial burden borne by our society as a consequence of falls and fractures was $24.2 billion in 2004.14 This is not an insignificant finding, and, considering the recent concerns that the drugs being prescribed to mothers and grandmothers to promote their bone health may actually be causing bone death,15 non-drug efforts to reduce the societal cost of fractures are worth the effort of further research. As we endeavor to do so, however, we must always place the safety of our patients above all other concerns. As quoted by Wysocki et al. in a comparative effectiveness review by the Agency for Healthcare Research and Quality, questions such as the optimal population that could benefit from WBV therapy and the ideal treatment protocol for osteoporosis remain unanswered; as I stated earlier, EBP favors research into fields where it is needed. However, in their research, Wysocki et al. noted that “safety concerns emerged . . . including unknown long-term harms from the use of whole-body vibration therapy, and the potential inability of consumers to clearly distinguish low-intensity platforms intended for osteoporosis therapy from platforms intended for high intensity exercise.”16 

 

A greater sustained research effort has been made about the potential negative effects of WBV therapy than has been done concerning its potential benefits. Because of the detailed research conducted by the International Standards Organization, OSHA, and others, we can state with confidence that the safety of WBV therapy has been validated, but only for specific frequencies, amplitudes, and durations, and under specific conditions.17 Exceeding these established safe levels is dangerous, just as exercising too much can be harmful to your health. For instance, there is no published research showing any negative effect to exposure to vibration at 30 Hz and 0.3 g, and the established guidelines for the safety of WBV exposure indicate that four hours of exposure to vibration at this level would be required to exceed safe levels. 

 
:quoteright_open:Some chiropractors may be using WBV products in their offices which have the potential to harm their patients’ skeletal systems:quoteright_close:

When it comes to the safety of WBV, amplitude (measured in acceleration) is the most important factor in this regard. The human body is designed to operate in a 1.0 g environment, and we can safely withstand forces at this level or below it for long periods. We can also tolerate short exposures to g-forces in excess of this amount (when we jump and land, for instance, that’s a short-term exposure to increased g’s). It is important to recognize, then, that according to Clinton Rubin, “g-forces that greatly exceed 1.0 are the very basis of devices referred to as PowerPlate, Galileo, SoloFlex, Galaxy, Nemes, and others, and should be approached with extreme caution. Conditioned athletes, should they knowingly understand these dangers and still wish to put their body at risk is one thing, but to use interventions on the elderly, osteoporotic, or functionally impaired individuals is dubious, at best.”18 When Rubin’s statement is combined with the statement made by Wysocki et al. regarding “the potential inability of consumers to clearly distinguish low-intensity platforms intended for osteoporosis therapy from platforms intended for high intensity exercise,” it should be readily apparent that some chiropractors may be using WBV products in their offices which have the potential to harm the skeletal systems of their patients. What, then, is the difference between the chiropractor claiming to help elderly patients with osteoporosis by exposing them to dangerous levels of vibration, and the medical doctor who treats osteoporosis by prescribing drugs that may cause bone death? 

 

A constant amplitude will change with increasing load; someone weighing 80 lbs is going to experience greater g-forces than someone weighing 180 lbs because increased weight will dampen the vibration. Amplitude can also vary depending upon foot placement, especially with oscillating platforms; the farther away your feet are from the axis of rotation, the greater the forces inputted into the body. While amplitude is the primary variable of interest, frequency also factors into the safety equation as well; for example, it’s easy to move your hand up and down three inches twice in one second. However, try moving your hand up and down three inches eighteen times in one second; this requires a great deal more exertion of force and the result is a higher amount of kinetic energy. So, in reviewing the literature, in order to have a safe product, you should ensure that the maximum amplitude never exceeds 1.0 g, and preferably remains closer to 0.2 or 0.3 g. This is an especially important concern with children, as their lighter weights will result in increased amplitude, and exposure to excessive vibratory forces could potentially affect the growth plates in a negative manner. If using an oscillating device, correct foot placement must be determined with care. In one report, a healthy athlete experienced hematuria (blood in the urine) after using an oscillating platform; the researchers suggested that something as simple as foot placement may have been at fault for the traumatic forces.19

I hope this article will serve as a warning to the chiropractic clinician who has purchased an unsafe vibration therapy product, and as an admonition to the manufacturers who are profiting without considering the true impact of their products upon those who use them. As the public becomes educated regarding the harmful effects of the misuse of WBV therapy, these individuals and organizations will increasingly render themselves vulnerable to the legal consequences of their decisions in the same manner that searching on the web for bisphosphonates and osteonecrosis brings up numerous articles written by attorneys. 

 

 

 

:dropcap_open:T:dropcap_close:here is no question that the root of chiropractic lies in the use of the hands on the axial spine and pelvis. It has been something originally developed by D.D. Palmer and passed down the ages from our forefathers to us. It is important to remember the roots of our profession as placing the hands on the spine releases innate power so the body can heal itself. Traditional chiropractic has helped us all form a strong foundation for the knowledge we use in daily practice. In school, we start with the basic understanding of anatomy and working with patients helps reinforce the key relationships between the bones, joints and muscles. In just about every patient, we observe the biomechanics of not only the spine, but of the extraspinal areas as well. 

 

The concept of extremity adjusting has been growing in momentum, especially in the last 10 years. In the past some have been lukewarm at the idea of truly adjusting anything but the spine. They felt extremity adjusting was not part of chiropractic. If we adjust the spine, it should be able to heal the body, right? In many cases, this is quite true. In many cases, however, this is not.

 

There are instances when the extremities themselves are the standalone causes of pain and without treating them, we are not addressing the true nature or source of the problem. Just as we ask patients to be open minded when getting their spine adjusted for the first time, so must we be when considering the extremities.

One of the main reasons why some of us do not gravitate towards adjusting extremities is because of the perception we are saddled with by the general public. Chiropractors are stereotypically pigeonholed as “back and neck doctors.” Patients do not realize that we can also treat the extremities. In fact, many of your patients right now have no idea you have the ability to do this; unless you tell them and show them!

 

Getting exposed to extremity anatomy and adjusting in chiropractic school was one thing. Really using the information and developing your skills in this area is another. Whether you are seasoned at working with extremities or a novice, practice, practice, practice helps bring confidence and great results.

 

It is amazing to assess someone’s foot, ankle, hip, hand, wrist, shoulder or TMJ when they are in pain. The power and effect of our hands to realign those bones is marvelous. Seeing the improved motion, muscle relaxation and pain reduction is just as amazing in an extremity as it is in the spine.

 

Often there are examples of spinal pain caused by an extremity. The most common example of this in my practice is lower back pain that is actually coming from the collapse or over pronation of the three arches of the feet. Once the foot arches drop downwards and the feet fall to the floor, there is an inward rotation of the tibia and femur bones that put lateral pressure on the hips. The resulting tipping of the pelvis stresses the lumbosacral region creating muscle hypertonicity, altered biomechanics and pain. This example is so common in my office that if I missed checking the feet, I would never be able to stabilize the lower back.

 

Another example is upper/mid back, neck pain and headaches that are caused by shoulder girdle misalignments. When the glenohumeral, the acromioclavicular and the sternoclavicular joints are subluxated, the humeral head tends to move anteriorly. The resultant stress on the clavicle, ribs and scapula eventually create hypertonicity in the surrounding muscles. Of these, trapezius muscle hypertonicity (due to its’ origins on the mid/upper back, neck and occiput) especially creates a lot of pain and reduced shoulder biomechanics. Very often, shoulder misalignments will present as spinal pain. If we miss the shoulder joints, it will hard to completely stabilize the region.

 

:dropcap_open:Chiropractors are stereotypically pigeonholed as “back and neck doctors.”

Just about every joint in the body has the potential to subluxate or misalign. How many times have you found someone’s jaw to be out of alignment? How about when ribs go out of place? The extremity joints are prime examples of these. All of them can exhibit the same kind of pain, local muscle hypertonicity and swelling that we see in the spine. 

 

Often, these smaller joints are located in areas of the body that are very critical to everyday activities. Try going about your daily routine when your wrist is hurting or you can’t put weight on your foot/ankle because these areas are out of alignment. What is important here is for you to think of the big picture. Although we should always address the pain, try not to chase it! The body likes to fool us sometimes.

 

The more proficiency you have with analyzing and adjusting the extremities, the more patients you will help. It is rare to find any patient who does not have some kind of ache and pain in an extraspinal body part. The more people you treat, the more extremity issues you will find. It’s a bit tricky at first, but you will get the feel for working with them. 

 

The nice thing about adjusting extremities is that there does not tend to be as much soft tissue to have to work through or push through to get right on the bones of the joint. Palpation is a bit easier as a result. This allows you to really feel when the bones are misaligned, especially comparing bilaterally. This ease of palpation allows you to assess range of motion, swelling, tenderness and general anatomy of the area without too much difficulty.

 

The body ends up being a sum of its parts. Your knowledge of the spine can only be strengthened by your extremity work. You start to put together patterns that the body exhibits when the extremities are out of sorts. It helps you become a better practitioner and it opens a whole new source of patients you can help. 

 

Extremities have always been so fascinating to me but getting really proficient with them is a skill I keep developing every day. I hope that wherever you are in your career, you see extremity adjusting as an important component to your practice. I hope working on these areas enhances your practice as much as it has mine. 

Dr. Kevin M. Wong is an expert on foot analysis, walking and standing postures and orthotics. Teaching patients and chiropractors is a passion for him, and he travels the country speaking about spinal and extremity adjusting. Dr. Wong practices full-time in Orinda, California. Contact Dr. Wong at 925-254-4040 or [email protected].

 

:dropcap_open:I:dropcap_close: can honestly say, after 27 years in practice, there has never been a better time to start a career in Chiropractic. Even with national healthcare reform moving forward, you can build a practice of your dreams by following some simple rules and taking time to look before you leap.

 

It was President Ronald Regan who said, “Trust, but verify,” and it is still good advice today. You have so many things to consider in opening or joining a practice. Do not let the excitement of getting into practice lead you into making decisions that you may later regret. Take time to complete a careful review of associate agreements, building and equipment leases and provider agreements. Before you sign anything or join an existing practice, use your head and seek wise counsel from trusted colleagues and/or legal counsel. Never just take someone’s word for what you should and should not do, can and cannot do when it comes to running your practice or what is acceptable in operating a practice. This is not meant to be harsh toward those with good intentions who are offering advice to help you succeed, but it is meant to encourage you to protect your license to practice. As a medical compliance specialist, I  have seen far too many cases where a doctor is facing fines and penalties and their only defense is, “Well, my buddy said it was okay and he does it all the time,” or “I heard my board of examiners said it was okay.” Verify what you hear about your state’s rules and regulations with your board of examiners, your state association, a trusted consultant, or established colleague with an impeccable reputation. When possible get verification in writing. This is most important when it comes to billing, coding, documentation and financial policy. Why? Because signing a bad lease can surely cost you money and aggravation. But improper billing, coding, documentation or faulty financial policies that lead to dual fee schedules or inducement violations can cause you serious financial harm, or worse, can cause you to lose your license. Game over. 

 
2. Never forget, your license is a privilege to practice… not a right.
Despite the years and thousands of hours devoted to completing chiropractic college and for some, hundreds of thousands of dollars spent, never forget, your license to practice is not a right but a privilege. And like any privilege, it can be taken away. Your license is extremely valuable and should be treated as such. Do not jeopardize your license by engaging in or participating in poor business practices or joining a practice that can clearly put you at risk. Violating rules and regulations from your Board of Examiners is bad enough, but the risks do not stop there. Make sure that your new practice, or the practice you join, is in compliance at all levels, from your State Board of Chiropractic Examiners or other licensing boards to the Department of Insurance for your state. Also, consider the rules and regulations from your Provider Agreements, State and Federal Anti-kickback Statutes, the Centers for Medicare and Medicaid (CMS/Medicare) and the Office of Inspector General (OIG). While this may seem overwhelming, it really is not that hard to accomplish with the proper guidance. If and when you find there are rules that conflict, and they do at times, take the safest and most conservative approach in determining your policy and document in your compliance manual what your decision was based on. Again, protect your license. It is, in essence, your passport for life to prosperity, so guard it carefully.

3. Remember, times are never good or bad, they are just different.
You may have heard of the Mercedes ‘80s, a time when you could put anything on an insurance claim form, send it in, and a check appeared. Or perhaps you have heard the horror stories of managed care where only two visits were permitted by an insurance carrier. Having practiced through these times, as you might imagine, the truth lies somewhere in between. Never was it that easy in the 1980s, and if you documented properly to support medical necessity, rarely would you be limited to two visits. What is clear and beyond debate now is that you are entering practice at a time where all professions, including chiropractic, are under more scrutiny than ever before. There are more fraud and abuse investigations now than at any other time in history. Billions of dollars are being recouped by the federal government and insurance companies for fraudulent claims. It has been reported that the Office of Inspector General stated that for every dollar spent in healthcare fraud and abuse investigations, they recoup $17.00. So, do not look for audits to decrease; they are making money. Unfortunately, some of the scrutiny in chiropractic is warranted, and it will continue. My intent is not to instill fear, but to empower you with facts so you can minimize the risks of audits, fines and penalties and practice with some peace of mind.

Here is the UPSIDE!
:dropcap_open:Again, protect your license. It is, in essence, your passport for life to prosperity, so guard it carefully.:quoteleft_close:
More doctors are taking a look at their billing, coding and documentation and are taking steps to be more compliant with all the layers of regulations. Make sure you start off the right way by knowing and following the rules. If you are joining an existing practice, make sure you know they are aware of the rules and regulations and are proactive in making sure they are running their practice in a compliant fashion. I can tell you, far too many docs like me who have been practicing for many years ignore the fact that the rules have changed, and we must change. If you run into a great opportunity to join a practice, but the doc’s head is in the sand, use the opportunity to help them bring needed change to their practices if they are open to it. If they are not, then it is simply not in your best interest to join that practice.

4. Know how joining an existing practice can put you at risk.
When you treat a patient, whether in your own practice or not, you have an NPI number that is recorded on the claim form. The NPI identifies you as the treating/ordering doctor. Even if someone else owns the clinic, your NPI is on the claim form and you are responsible and accountable for what is on the claim form. Box 31 of the CMS 1500 form is an attestation that the information is accurate, and you agree to the statements on the reverse side of the form, including:

I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations.

So whether you are personally responsible for sending out the claims or not, you are held responsible because you have allowed them to use your NPI number as the treating/ordering doctor, and you are at risk if the practice is not operating in a compliant fashion.

5. Look and ask before you leap.
If you have decided to join an existing practice, even the family practice, there are things to consider and respectfully ask about before signing on. Yes, it is okay to ask questions of mom and dad or other family members. As a second generation chiropractor who did, I can tell you it may not be easy, but you have a right and an obligation to know some key things about the practice. Here is a short list:

• Do you have sound financial and billing policies in writing? Ask for a copy and review them.

• Is there more than one fee schedule? If so, why? And is it legal? In some states, charging more to insurance patients than you do for cash patients is considered a “dual fee schedule” and could be illegal. Ideally, there should be one fee schedule. One of the safest policies is to only offer discounts when they are part of a written financial policy, which could include contractual or network discounts, mandated fees like those established by Medicare, or when there is a documented financial hardship. Other legal discounts could include a defensible time of service or prompt payment discount, if and only if permitted in your state. If you would like a copy of a simple, one page financial policy that is rock solid, send an email to [email protected] and put FORM in the subject line.

• Does the clinic up code, or down code based on the type of insurance coverage? Meaning, do they bill a higher level of Evaluation & Management code for PI or Worker’s Compensation cases and a low-level code just because they are cash patients?

• Do you waive deductibles or co-payments? This is clearly a violation of rules and regulations and most provider agreements unless a true financial hardship is established by the clinic.

• Do you have a written financial policy that is covered with patients? Many complaints to Boards of Examiners seem to be triggered by a poor financial policy, which is easily eliminated by written policy.

• Does the clinic have a compliance plan in place to minimize the potential for fraud and abuse and to ensure compliance with all layers of regulations? There are many steps that can be taken today to minimize the potential for audits and mitigate potential fines and penalties.

• Has the practice ever been audited? If so, what was the outcome? Today, it is not a matter of if you will be audited, but when. And, keep in mind, just because there has been an audit does not mean someone did something wrong. It could just be their number came up.

Finally, despite what seems like a list of overwhelming decisions and concerns, you are embarking on a career as a doctor of chiropractic at a time that has opportunities like we have never seen before. Expect the best, give your best to the profession and your patients, and you will not be disappointed.

Dr. Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. He has served as  president of the Mississippi Chiropractic Association, former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center and is a  Fellow of the International College of Chiropractic. He founded ConservaCareCorp, the first chiropractic network selected by the State of Mississippi to serve over 195K covered lives in the State Health Plan. You can contact Dr. Foxworth at 1-888-719-9990, [email protected] or visit the ChiroHealthUSA website at www.chirohealthusa.com